Provider Demographics
NPI:1124615398
Name:PAUGH, IVY RICCOLE
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:RICCOLE
Last Name:PAUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ELM DR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1628
Mailing Address - Country:US
Mailing Address - Phone:304-694-0359
Mailing Address - Fax:
Practice Address - Street 1:405 ELM DR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1628
Practice Address - Country:US
Practice Address - Phone:304-694-0359
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant